05-23239. Privacy Act of 1974; Report of a New System of Records

AGENCY:

Centers for Medicare & Medicaid Services (CMS), Department of Health and Human Services (HHS).

ACTION:

Notice of a new System of Records (SOR).

SUMMARY:

In accordance with the requirements of the Privacy Act of 1974, we are proposing a new SOR titled, “National Disaster Medical System (NDMS) Claims Processing System (CPS), No. 09-70-0572.” CMS is responsible for establishing and administering a payment mechanism for definitive medical care provided under the National Disaster Medical System (NDMS) in accordance with section 2811 of the Public Health Service Act, 42 United States Code (U.S.C.) 300hh-11, a Memorandum of Agreement (MOA) entered into by the NDMS Partners—the Departments of Homeland Security, Health and Human Services, Defense, and Veteran's Affairs, and an Inter-Agency Agreement between CMS and the Federal Emergency Management Agency (FEMA). Reimbursement to NDMS-participating hospitals (and practitioners furnishing medical services to NDMS-authorized patients during inpatient stays in those hospitals) for definitive medical care will be administered through the NDMS-CPS. The new system will collect data relating to individuals who receive NDMS-authorized medical treatment or services in NDMS hospitals for illness or injury resulting from a specified public health emergency or non-deferrable medical treatment or services to maintain health when such are temporarily not available as a result of the public health emergency. Data on individuals will be submitted by the Departments of Defense and Veteran's Affairs, staffed Federal Coordinating Centers activated by the NDMS, NDMS hospitals, and practitioners within NDMS hospitals that furnish medical treatment or services to NDMS patients.

The primary purpose of the system is to justify and document payments for inpatient hospital and related practitioner services provided in connection to the NDMS. Information in this system will also be disclosed to: (1) Support regulatory, reimbursement, and policy functions performed by CMS and the NDMS Partners, contractors (including the NDMS claims contractor), and consultants contracted by the Agency; (2) support another Federal (including the NDMS Partners) agency of a state government, an agency established by state law, or its fiscal agent; (3) assist NDMS-participating hospitals (and practitioners within those hospitals) who have furnished services to individuals evacuated and placed by the NDMS; (4) assist third party contacts in situations where the party to be contacted has, or is expected to have information relating to the individual's capacity to manage his or her affairs; (5) facilitate research on the quality and effectiveness of care provided, as well as payment-related projects; (6) support constituent requests made to a congressional representative; (7) support litigation involving the Agency, and (8) combat fraud and abuse in certain Federal health benefits programs. We have provided background information about the new system in the Supplementary Information section below. Although the Privacy Act requires only that CMS provide an opportunity for interested persons to comment on the proposed routine uses, CMS invites comments on all portions of this notice. See Effective Dates section for comment period.

EFFECTIVE DATES:

CMS filed a new system report with the Chair of the House Committee on Government Reform and Oversight, the Chair of the Senate Committee on Governmental Affairs, and the Administrator, Office of Information and Regulatory Affairs, Office of Management and Budget (OMB) on November 17, 2005. To ensure that all parties have adequate time in which to comment, the new SOR and the routine uses, will become effective 30 days from the publication of the notice, provided OMB grants CMS' request for a 10-day waiver of the review period, unless CMS receives comments that require alterations to this notice. If OMB does not grant CMS' request for a 10-day waiver of the review period, the new SOR and the routine uses, will become effective 30 days from the publication of the notice, or 40 days from the date it was mailed to OMB and Congress, whichever is later, unless CMS receives comments that require alterations to this notice.

ADDRESSES:

The public should address comments to: CMS Privacy Officer, Division of Privacy Compliance Data Development (DPCDD), CMS, Mail Stop N2-04-27, 7500 Security Boulevard, Baltimore, Maryland 21244-1850. Comments received will be available for review at this location, by appointment, during regular business hours, Monday through Friday from 9 a.m.-3 p.m., Eastern daylight time.

FOR FURTHER INFORMATION CONTACT:

Chris Klots, Technical Advisor, Medicare Contractor Management Group, Center for Medicare Management, CMS, Mail Stop S1-14-17, 7500 Security Boulevard, Baltimore, MD 21244-1850. He can also be contacted by telephone at 410-786-3348, or e-mail at [e-mail].

SUPPLEMENTARY INFORMATION:

The NDMS is a partnership of four Federal agencies—HHS, Department of Defense, Department of Veteran's Affairs and the Department of Homeland Security. In a disaster situation, the NDMS augments the public health and health care activities of State and local governments. NDMS has three key functions to which each of the Partners contribute: Medical response, patient evacuation, and definitive medical care.

The medical response function of NDMS relates to the deployment of NDMS response teams, comprised of trained medical and logistical personnel from the NDMS Federal Partners, to assess the health and medical needs of disaster victims and to respond to these needs and patients. The patient evacuation function of NDMS relates to the establishment of a communications, transportation and medical regulating system to evacuate patients from a mobilization center near the disaster site, to patient reception capabilities known as Federal Coordinating Centers. The Departments of Defense and Veteran's Affairs are responsible for activating and staffing the Federal Coordinating Centers. The Federal Coordinating Centers have the authority to arrange for referral and inpatient admission of NDMS-evacuated patients in acute care hospitals for definitive medical care. The definitive medical care is provided by hospitals that are part of the NDMS and have agreed to provide this inpatient care to NDMS evacuees on an as-needed basis.

CMS is responsible for establishing and administering a payment mechanism for definitive medical care provided under the NDMS in accordance with section 2811 of the Public Health Service Act, 42 U.S.C. 300hh-11, a MOA entered into by the NDMS Partners—the Departments of Homeland Security, Health and Human Services, Defense, and Veteran's Affairs, and an Inter-Agency Agreement between CMS and FEMA. Reimbursement to NDMS-participating hospitals (and practitioners furnishing medical services to NDMS-authorized patients during inpatient stays in those hospitals) for definitive medical care will be administered through the NDMS-CPS. The new system will collect data relating to individuals who receive NDMS-authorized medical treatment or services in NDMS hospitals for illness or injury resulting from a specified public health emergency or non-deferrable medical treatment or services to maintain health when such are temporarily not available as a result of the public health emergency. Data on individuals will be submitted by the Departments of Defense and Veteran's Affairs, staffed Federal Coordinating Centers activated by the NDMS, NDMS hospitals, and practitioners within NDMS hospitals that furnish medical treatment or services to NDMS patients.

The NDMS MOA defines NDMS definitive medical care as follows: to the extent authorized by NDMS in a particular public health emergency, medical treatment or services beyond emergency medical care, initiated upon inpatient admission to an NDMS treatment facility and provided for injuries or illnesses resulting directly from a specified public health emergency, or for injuries, illnesses and conditions requiring non-deferrable medical treatment or services to maintain health when such medical treatment and services are temporarily not available as a result of the public health emergency. Other provisions of the NDMS MOA make clear that NDMS coverage ends when the indicated medical treatment is completed, the patient refuses care, the patient is returned home, or thirty days elapse.

Accordingly, in order to provide expeditious processing and adjudication of NDMS definitive medical claims from NDMS hospitals and licensed providers arising from NDMS-authorized medical treatment and services for victims of a public health emergency, a contractor will collect and process NDMS patient data gathered by the Federal Coordinating Centers during the emergency evacuations against NDMS claims data, with CMS subsequently making payment on appropriate claims in keeping with NDMS policies. Subject to the availability of funds, a similar solution will be employed to address NDMS definitive medical care reimbursement requirements that may arise in future emergency situations.

I. Description of the New System of Records

A. Statutory and Regulatory Basis for the System

Authority for reimbursement of providers is found under section 102(a) of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Public Law 107-188, which added section 2811 of the Public Health Service Act, 42 U.S.C. 300hh-11, as transferred to the Department of Homeland Security under the Homeland Security Act of 2002, Pub. L. 107-296, 6 U.S.C. 313(5), and the Economy Act, 31 U.S.C. 1535.

B. Collection and Maintenance of Data in the System

The new system will collect data from individuals who receive treatment for services in an NDMS hospital for illness or injury resulting from a specified public health emergency or non-deferrable medical treatment or services to maintain health when such are temporarily not available as a result of the public health emergency. Patient data will be collected by the Federal Coordinating Centers and claims data on medical treatment and services furnished to NDMS-authorized patients will be reported by NDMS-participating hospitals (and practitioners within those facilities) to a CMS-contracted claims processor who will process claims under the NDMS-CPS. The system will also include, but is not limited to, name, social security number, address, dates of care, Diagnostic Related Group/Current Procedure Terminology (DRG/CPT) data, provider name, provider address, provider number, amount billed, amount allowed, other insurance payment, amount to be paid, and applicable Employer Identification Number.

II. Agency Policies, Procedures, and Restrictions on Routine Uses

A. The Privacy Act permits us to disclose information without an individual's consent if the information is to be used for a purpose that is compatible with the purpose(s) for which the information was collected. Any such disclosure of data is known as a “routine use.” The government will only release NDMS-CPS information that can be associated with an individual as provided for under “Section III. Proposed Routine Use Disclosures of Data in the System.” Both identifiable and non-identifiable data may be disclosed under a routine use.

We will only collect the minimum personal data necessary to achieve the purpose of NDMS-CPS. CMS has the following policies and procedures concerning disclosures of information that will be maintained in the system. Disclosure of information from the system will be approved only to the extent necessary to accomplish the purpose of the disclosure and only after CMS:

1. Determines that the use or disclosure is consistent with the reason data is being collected; e.g., to justify and document payments for inpatient hospital and related practitioner services provided in connection to the NDMS.

2. Determines that the purpose for which the disclosure is to be made can only be accomplished if the record is provided in individually identifiable form;

a. The purpose for which the disclosure is to be made is of sufficient importance to warrant the effect and/or risk on the privacy of the individual that additional exposure of the record might bring; and

b. There is a strong probability that the proposed use of the data would in fact accomplish the stated purpose(s).

3. Requires the information recipient to:

a. Establish administrative, technical, and physical safeguards to prevent unauthorized use of disclosure of the record;

b. Remove or destroy at the earliest time all patient-identifiable information; and

c. Agree to not use or disclose the information for any purpose other than the stated purpose under which the information was disclosed.

4. Determines that the data are valid and reliable.

III. Routine Use Disclosures of Data in the System

A. Entities Who May Receive Disclosures Under Routine Use:

These routine uses specify circumstances, in addition to those provided by statute in the Privacy Act of 1974, under which CMS may release information from the NDMS-CPS without the consent of the individual to whom such information pertains. Each proposed disclosure of information under these routine uses will be evaluated to ensure that the disclosure is legally permissible, including but not limited to ensuring that the purpose of the disclosure is compatible with the purpose for which the information was collected. We are proposing to establish the following routine use disclosures of information maintained in the system:

1. To CMS contractors (including the NDMS claims contractor), or consultants who have been contracted by the Agency to assist in accomplishment of a CMS function relating to the purposes for this system and who need to have access to the records in order to assist CMS.

We contemplate disclosing information under this routine use only in situations in which CMS may enter into a contractual or similar agreement with a third party to assist in accomplishing an NDMS claims processing function or other CMS function relating to purposes for this system.

CMS occasionally contracts out certain of its functions when doing so would contribute to effective and efficient operations. CMS must be able to give a contractor or consultant whatever information is necessary for the contractor or consultant to fulfill its duties. In these situations, safeguards are provided in the contract prohibiting the contractor or consultant from using or disclosing the information for any purpose other than that described in the contract and requires the contractor or consultant to return or destroy all information at the completion of the contract.

2. To another Federal agency (including any of the NDMS Partner Agencies), an agency of a State government, an agency established by State law, or its fiscal agent to:

a. contribute to the accuracy of CMS's proper payment of Medicare benefits,

b. enable such agency to administer a Federal health benefits program, or as necessary to enable such agency to fulfill a requirement of a Federal statute or regulation that implements a health benefits program funded in whole or in part with Federal funds, and/or

c. assist Federal/State Medicaid programs within the State.

Other Federal or State agencies in their administration of a Federal health program may require NDMS-CPS information in order to support evaluations and monitoring of the NDMS program, including proper reimbursement for services provided.

In addition, other State agencies in their administration of a Federal health program may require NDMS-CPS information for the purposes of determining, evaluating and/or assessing cost, effectiveness, and/or the quality of health care services provided in the state.

Disclosure under this routine use shall be used by State Medicaid agencies pursuant to agreements with the HHS for determining Medicaid eligibility, for quality control studies, for determining eligibility of recipients of assistance under Titles IV, and XIX of the Social Security Act (the Act), and for the administration of the Medicaid program. Data will be released to the state only on those individuals who are patients under the services of a Medicaid program within the State or who are residents of that State.

We also contemplate disclosing information under this routine use in situations in which State auditing agencies require NDMS-CPS information for auditing State Medicaid eligibility considerations. CMS may enter into an agreement with State auditing agencies to assist in accomplishing functions relating to purposes for this system.

3. To providers and practitioners who have furnished NDMS-authorized medical treatment and/or services to individuals evacuated and placed for NDMS definitive medical care by the NDMS.

Providers and suppliers of services may require NDMS-CPS information in order to establish the validity of evidence or to verify the accuracy of information presented by the individual, as it concerns the individual's entitlement to benefits under the NDMS program, including proper reimbursement for services provided.

4. To third party contacts in situations where the party to be contacted has, or is expected to have information relating to the individual's capacity to manage his or her affairs or to his or her eligibility for, or an entitlement to, benefits under the NDMS program and,

a. The individual is unable to provide the information being sought (an individual is considered to be unable to provide certain types of information when any of the following conditions exists: the individual is confined to a mental institution, a court of competent jurisdiction has appointed a guardian to manage the affairs of that individual, a court of competent jurisdiction has declared the individual to be mentally incompetent, or the individual's attending physician has certified that the individual is not sufficiently mentally competent to manage his or her own affairs or to provide the information being sought, the individual cannot read or write, cannot afford the cost of obtaining the information, a language barrier exist, or the custodian of the information will not, as a matter of policy, provide it to the individual), or

b. The data are needed to establish the validity of evidence or to verify the accuracy of information presented by the individual, and it concerns one or more of the following: the individual's entitlement to benefits under the NDMS program, the amount of reimbursement, and in cases in which the evidence is being reviewed as a result of suspected fraud and abuse, program integrity, quality appraisal, or evaluation and measurement of activities.

Third party contacts may require NDMS-CPS information in order to provide support for the individual's entitlement to benefits under the NDMS program; to establish the validity of evidence or to verify the accuracy of information presented by the individual, and assist in the monitoring of NDMS claims-related information for NDMS evacuees, including proper reimbursement of services provided.

5. To an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment-related projects.

NDMS-CPS data may be provided for research, evaluation, and epidemiological projects, in order to contribute to a broader, longitudinal, national perspective of the status of NDMS patients. CMS anticipates that many researchers may have legitimate requests to use these data in projects that could ultimately improve the care provided to disaster victims and the policy that governs the care.

6. To a Member of Congress or a Congressional staff member in response to an inquiry of the Congressional office made at the written request of the constituent about whom the record is maintained.

Individuals often request the help of a Member of Congress in resolving some issue relating to a matter before CMS. The Member of Congress then writes CMS, and CMS must be able to give sufficient information in response to the inquiry.

7. To the Department of Justice (DOJ), court or adjudicatory body when:

a. the Agency or any component thereof, or

b. any employee of the Agency in his or her official capacity, or

c. any employee of the Agency in his or her individual capacity where the DOJ has agreed to represent the employee, or

d. the United States Government, is a party to litigation or has an interest in such litigation, and, by careful review, CMS determines that the records are both relevant and necessary to the litigation and that the use of such records by the DOJ, court or adjudicatory body is compatible with the purpose for which the agency collected the records.

Whenever CMS is involved in litigation, or occasionally when another party is involved in litigation and CMS's policies or operations could be affected by the outcome of the litigation, CMS would be able to disclose information to the DOJ, court, or adjudicatory body involved.

8. To a CMS contractor (including, but not limited to FIs and carriers) that assists in the administration of a CMS-administered health benefits program, or to a grantee of a CMS-administered grant program, when disclosure is deemed reasonably necessary by CMS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud or abuse in such programs.

We contemplate disclosing information under this routine use only in situations in which CMS may enter into a contract or grant with a third party to assist in accomplishing CMS functions relating to the purpose of combating fraud and abuse.

CMS occasionally contracts out certain of its functions when doing so would contribute to effective and efficient operations. CMS must be able to give a contractor or grantee whatever information is necessary for the contractor or grantee to fulfill its duties. In these situations, safeguards are provided in the contract prohibiting the contractor or grantee from using or disclosing the information for any purpose other than that described in the contract and requiring the contractor or grantee to return or destroy all information.

9. To another Federal agency or to an instrumentality of any governmental jurisdiction within or under the control of the United States (including any State or local governmental agency), that administers, or that has the authority to investigate potential fraud or abuse in, a health benefits program funded in whole or in part by Federal funds, when disclosure is deemed reasonably necessary by CMS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud or abuse in such programs.

Other agencies may require NDMS-CPS information for the purpose of combating fraud and abuse in such federally-funded programs.

B. Additional Circumstances Affecting Routine Use Disclosures:

To the extent this system contains Protected Health Information (PHI) as defined by HHS regulation “Standards for Privacy of Individually Identifiable Health Information” (45 CFR parts 160 and 164, 65 FR 82462 (12-28-00), subparts A and E). Disclosures of such PHI that are otherwise authorized by these routine uses may only be made if, and as, permitted or required by the “Standards for Privacy of Individually Identifiable Health Information.”

In addition, our policy will be to prohibit release even of data not directly identifiable, except pursuant to one of the routine uses or if required by law, if we determine there is a possibility that an individual can be identified through implicit deduction based on small cell sizes (instances where the patient population is so small that individuals who are familiar with the enrollees could, because of the small size, use this information to deduce the identity of the beneficiary).

IV. Safeguards

CMS has safeguards in place for authorized users and monitors such users to ensure against excessive or unauthorized use. Personnel having access to the system have been trained in the Privacy Act and information security requirements. Employees who maintain records in this system are instructed not to release data until the intended recipient agrees to implement appropriate management, operational and technical safeguards sufficient to protect the confidentiality, integrity and availability of the information and information systems and to prevent unauthorized access.

This system will conform to all applicable Federal laws and regulations and Federal, HHS, and CMS policies and standards as they relate to information security and data privacy. These laws and regulations may apply but are not limited to: the Privacy Act of 1974; the Federal Information Security Management Act of 2002; the Computer Fraud and Abuse Act of 1986; the Health Insurance Portability and Accountability Act of 1996; the E-Government Act of 2002, the Clinger-Cohen Act of 1996; the Medicare Modernization Act of 2003, and the corresponding implementing regulations. OMB Circular A-130, Management of Federal Resources, Appendix III, Security of Federal Automated Information Resources also applies. Federal, HHS, and CMS policies and standards include but are not limited to: All pertinent National Institute of Standards and Technology publications; the HHS Information Systems Program Handbook and the CMS Information Security Handbook.

V. Effects of the System on Individual Rights

CMS proposes to establish this system in accordance with the principles and requirements of the Privacy Act and will collect, use, and disseminate information only as prescribed therein. Data in this system will be subject to the authorized releases in accordance with the routine uses identified in this system of records.

CMS will take precautionary measures to minimize the risks of unauthorized access to the records and the potential harm to individual privacy or other personal or property rights of patients whose data are maintained in the system. CMS will collect only that information necessary to perform the system's functions. In addition, CMS will make disclosure from the proposed system only with consent of the subject individual, or his/her legal representative, or in accordance with an applicable exception provision of the Privacy Act. CMS, therefore, does not anticipate an unfavorable effect on individual privacy as a result of the disclosure of information relating to individuals.

Dated: November 7, 2005.

Charlene Frizzera,

Acting Chief Operating Officer, Centers for Medicare & Medicaid Services.

System No. 09-70-0572

System Name:

“National Disaster Medical System Claims Processing System (NDMS-CPS)” HHS/CMS/CMM.

Security Classification:

Level Three Privacy Act Sensitive.

System Location:

CMS Data Center, 7500 Security Boulevard, North Building, First Floor, Baltimore, Maryland 21244-1850.

Categories of Individuals Covered By The System:

The new system will collect data from individuals who receive treatment for services in an NDMS hospital for illness or injury resulting from a specified public health emergency or non-deferrable medical treatment or services to maintain health when such are temporarily not available as a result of the public health emergency. Patient data will be collected by the Federal Coordinating Centers and claims data on medical treatment and services furnished to NDMS-authorized patients will be reported by NDMS-participating hospitals (and practitioners within those facilities) to a CMS-contracted claims processor who will process claims under the NDMS-CPS.

Categories Of Records In The System:

The system will include, but is not limited to, name, social security number (SSN), address, dates of care, Diagnostic Related Group/Current Procedure Terminology (DRG/CPT) data, provider name, provider address, provider number, amount billed, amount allowed, other insurance payment, amount to be paid, and applicable Employer Identification Number.

Authority For Maintenance Of The System:

Authority for reimbursement of providers is found under section 102(a) of the Public Health Security and Bioterrorism Preparedness and Response Act of 2002, Pub. L. 107-188, which added § 2811 of the Public Health Service Act, 42 U.S.C. 300hh-11, as transferred to the Department of Homeland Security under the Homeland Security Act of 2002, Pub. L. 107-296, 6 U.S.C. 313(5), and the Economy Act, 31 U.S.C. 1535.

Purpose(s) Of The System:

The primary purpose of the system is to justify and document payments for inpatient hospital and related practitioner services provided in connection to the NDMS. Information in this system will also be disclosed to: (1) Support regulatory, reimbursement, and policy functions performed by CMS and the NDMS Partners, contractors (including the NDMS claims contractor), and consultants contracted by the Agency; (2) support another Federal (including the NDMS Partners), agency of a State government, an agency established by state law, or its fiscal agent; (3) assist NDMS-participating hospitals (and practitioners within those hospitals) who have furnished services to individuals evacuated and placed by the NDMS; (4) assist third party contacts in situations where the party to be contacted has, or is expected to have information relating to the individual's capacity to manage his or her affairs; (5) facilitate research on the quality and effectiveness of care provided, as well as payment-related projects; (6) support constituent requests made to a congressional representative; (7) support litigation involving the Agency, and (8) combat fraud and abuse in certain Federal health benefits programs.

Routine Uses Of Records Maintained In The System, Including Categories Or Users And The Purposes Of Such Uses:

A. Entities Who May Receive Disclosures Under Routine Use:

These routine uses specify circumstances, in addition to those provided by statute in the Privacy Act of 1974, under which CMS may release information from the NDMS-CPS without the consent of the individual to whom such information pertains. Each proposed disclosure of information under these routine uses will be evaluated to ensure that the disclosure is legally permissible, including but not limited to ensuring that the purpose of the disclosure is compatible with the purpose for which the information was collected. We are proposing to establish the following routine use disclosures of information maintained in the system:

1. To Agency contractors (including the NDMS claims contractor), or consultants who have been contracted by the Agency to assist in accomplishment of a CMS function relating to the purposes for this system and who need to have access to the records in order to assist CMS.

2. To another Federal agency (including any of the NDMS Partner Agencies), an agency of a State government, an agency established by State law, or its fiscal agent to:

a. Contribute to the accuracy of CMS's proper payment of Medicare benefits,

b. Enable such agency to administer a Federal health benefits program, or as necessary to enable such agency to fulfill a requirement of a Federal statute or regulation that implements a health benefits program funded in whole or in part with Federal funds, and/or

c. Assist Federal/State Medicaid programs within the State.

3. To providers and practitioners who have furnished NDMS-authorized medical treatment and/or services to individuals evacuated and placed for NDMS definitive medical care by the NDMS.

4. To third party contacts in situations where the party to be contacted has, or is expected to have information relating to the individual's capacity to manage his or her affairs or to his or her eligibility for, or an entitlement to, benefits under the NDMS program and,

a. The individual is unable to provide the information being sought (an individual is considered to be unable to provide certain types of information when any of the following conditions exists: The individual is confined to a mental institution, a court of competent jurisdiction has appointed a guardian to manage the affairs of that individual, a court of competent jurisdiction has declared the individual to be mentally incompetent, or the individual's attending physician has certified that the individual is not sufficiently mentally competent to manage his or her own affairs or to provide the information being sought, the individual cannot read or write, cannot afford the cost of obtaining the information, a language barrier exist, or the custodian of the information will not, as a matter of policy, provide it to the individual), or

b. The data are needed to establish the validity of evidence or to verify the accuracy of information presented by the individual, and it concerns one or more of the following: The individual's entitlement to benefits under the NDMS program, the amount of reimbursement, and in cases in which the evidence is being reviewed as a result of suspected fraud and abuse, program integrity, quality appraisal, or evaluation and measurement of activities.

5. To an individual or organization for a research, evaluation, or epidemiological project related to the prevention of disease or disability, the restoration or maintenance of health, or payment-related projects.

6. To a Member of Congress or a congressional staff member in response to an inquiry of the congressional office made at the written request of the constituent about whom the record is maintained.

7. To the Department of Justice (DOJ), court or adjudicatory body when: The Agency or any component thereof, or

a. Any employee of the Agency in his or her official capacity, or

b. Any employee of the Agency in his or her individual capacity where the DOJ has agreed to represent the employee, or

c. The United States Government, is a party to litigation or has an interest in such litigation, and, by careful review, CMS determines that the records are both relevant and necessary to the litigation and that the use of such records by the DOJ, court or adjudicatory body is compatible with the purpose for which the agency collected the records.

8. To a CMS contractor (including, but not limited to FIs and carriers) that assists in the administration of a CMS-administered health benefits program, or to a grantee of a CMS-administered grant program, when disclosure is deemed reasonably necessary by CMS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud or abuse in such programs.

9. To another Federal agency or to an instrumentality of any governmental jurisdiction within or under the control of the United States (including any State or local governmental agency), that administers, or that has the authority to investigate potential fraud or abuse in, a health benefits program funded in whole or in part by Federal funds, when disclosure is deemed reasonably necessary by CMS to prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy, or otherwise combat fraud or abuse in such programs.

B. Additional Circumstances Affecting Routine Use Disclosures:

To the extent this system contains Protected Health Information (PHI) as defined by HHS regulation “Standards for Privacy of Individually Identifiable Health Information” (45 CFR parts 160 and 164, 65 FR 82462 (12-28-00), subparts A and E. Disclosures of such PHI that are otherwise authorized by these routine uses may only be made if, and as, permitted or required by the “Standards for Privacy of Individually Identifiable Health Information.”

In addition, our policy will be to prohibit release even of data not directly identifiable, except pursuant to one of the routine uses or if required by law, if we determine there is a possibility that an individual can be identified through implicit deduction based on small cell sizes (instances where the patient population is so small that individuals who are familiar with the enrollees could, because of the small size, use this information to deduce the identity of the beneficiary).

Policies And Practices For Storing, Retrieving, Accessing, Retaining, And Disposing Of Records In The System:

Storage:

Computer diskette, magnetic storage media, and paper claims.

Retrievability:

Information will be retrieved by patient's name and SSN; and may be sorted by geographical area or medical provider.

Safeguards:

CMS has safeguards in place for authorized users and monitors such users to ensure against excessive or unauthorized use. Personnel having access to the system have been trained in the Privacy Act and information security requirements. Employees who maintain records in this system are instructed not to release data until the intended recipient agrees to implement appropriate management, operational and technical safeguards sufficient to protect the confidentiality, integrity and availability of the information and information systems and to prevent unauthorized access.

This system will conform to all applicable Federal laws and regulations and Federal, HHS, and CMS policies and standards as they relate to information security and data privacy. These laws and regulations may apply but are not limited to: the Privacy Act of 1974; the Federal Information Security Management Act of 2002; the Computer Fraud and Abuse Act of 1986; the Health Insurance Portability and Accountability Act of 1996; the E-Government Act of 2002, the Clinger-Cohen Act of 1996; the Medicare Modernization Act of 2003, and the corresponding implementing regulations. Office of Management and Budget Circular A-130, Management of Federal Resources, Appendix III, Security of Federal Automated Information Resources also applies. Federal, HHS, and CMS policies and standards include but are not limited to: all pertinent National Institute of Standards and Technology publications; the HHS Information Systems Program Handbook and the CMS Information Security Handbook.

Retention And Disposal:

Records are maintained in a secure storage area with identifiers. Disposal occurs five years from the last action on the hospital's cost report, and should be coordinated with disposal of the reports. All claims-related records are encompassed by the document preservation order and will be retained until notification is received from DOJ.

System Manager And Address:

Director, Medicare Contractor Management Group, Center for Medicare Management, CMS, 7500 Security Boulevard, Baltimore, Maryland 21244-1850.

Notification Procedure:

For purpose of access, the subject individual should write to the systems manager who will require the system name, SSN, address, date of birth, sex, and for verification purposes, the subject individual's name (woman's maiden name, if applicable). Furnishing the SSN is voluntary, but it may make searching for a record easier and prevent delay.

Record Access Procedure:

For purpose of access, use the same procedures outlined in Notification Procedures above. Requestors should also reasonably specify the record contents being sought. (These procedures are in accordance with Department regulation 45 CFR 5b.5(a)(2)).

Contesting Record Procedures:

The subject individual should contact the system manager named above, and reasonably identify the record and specify the information to be contested. State the corrective action sought and the reasons for the correction with supporting justification. (These procedures are in accordance with Department regulation 45 CFR 5b.7).

Record Source Categories:

Information contained in this system will be submitted by NDMS hospitals, other providers, and States.

Systems Exempted From Certain Provisions Of The Act:

None.